Iboga Treatment Application

Are there any legal problems (bail, probation, parole) that would restrict your ability to travel abroad?

YesNo

Explain:

Pre-existing medical condition(s), surgeries/procedures:

Any special dietary considerations:

Please list all prescribed medication, drugs, or supplements you are currently taking, or have taken in the past six (6) months. Include dosage, frequency, method, and length of use:

Any history of cardiac problems/surgeries, diabetes, hypertension/high blood pressure?

Pre-existing mental health issue(s), including mood disorder(s):

Have you had EKG and bloodwork (liver enzymes, magnesium levels) in the last 30 days?

No. (No problem; we will do these tests when you arrive at our facility.)Yes. (Please arrange to send a copy to admin@newpathibogaine.com, dr.silva@newpathibogaine.com )

Would you describe your past psychedelic experience(s) as positive or negative? Please explain

Have you ever had hallucinations or a psychotic episode, whether connected with psychedelics or not?

Do you have any history of a mental health diagnosis, psychiatric admissions, suicidal ideations/attempts?

Are there any relatives who have a history of mental health issues, including psychiatric admissions and suicidal ideations/attempts?

Have you ever experienced paranoia, or a nervous breakdown due to stress or burnout?

Are you seeking to resolve any history of belligerent or assaultive behaviour, whether under the influence or not?